Active NPI
Kingsley U Johnetebom, RN
- Registered Nurse
- San Leandro, CA
National Provider Identifier
1346137866
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Nurse
- License
- 95413311
- Practice address
- 545 Estudillo Ave
San Leandro, CA 94577-4611 - Phone
- (510) 309-0003
- NPI assigned
- Jun 18, 2025
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Nurse | 163W00000X | 95413311 | CA | Primary |
Addresses
Primary practice location
545 Estudillo Ave
San Leandro, CA 94577-4611
Mailing address
545 Estudillo Ave
San Leandro, CA 94577-4611
Phone (510) 309-0003
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Registered Nurse
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 95413311 | CA | MD | Registered Nurse |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1750204800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1750204800000",
"number": "1346137866",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "545 ESTUDILLO AVE",
"city": "SAN LEANDRO",
"state": "CA",
"postal_code": "945774611",
"telephone_number": "510-309-0003"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "545 ESTUDILLO AVE",
"city": "SAN LEANDRO",
"state": "CA",
"postal_code": "945774611",
"telephone_number": "510-309-0003"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JOHNETEBOM",
"first_name": "KINGSLEY",
"middle_name": "U",
"credential": "RN",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2025-06-18",
"last_updated": "2025-06-18",
"certification_date": "2025-06-18",
"status": "A"
},
"taxonomies": [
{
"code": "163W00000X",
"taxonomy_group": "",
"desc": "Registered Nurse",
"state": "CA",
"license": "95413311",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Leandro, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 18, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.